True, but the fact that the law says premiumscan equal 9.5% of income doesn’t means that employer-sponsored insurance willcost 9.5% of a worker’s pay.

Nevertheless, Yahoo! conjures up a hypothetical employee who will be left out in the cold: “Take, for example, a restaurant worker who makes $21,000 per year. A premium that costs 9.5 percent of this income would run $1,995 for the whole year, or $166.25 per month. How could this employee possibly shell out nearly $2,000 a year for insurance?”

He will have to turn down his employer’s offer, and then the government will demand that he pay a penalty because he didn’t buy insurance!

The Washington Post quotes Shannon Demaree, an insurance broker and benefits consultant with the Lockton Benefit Group, declaring that, with for many people, “there is just not anything left over for health insurance . . . What the government is requiring employers to do isn’t really something their low-paid employees want.”

Fictions vs. Facts

— Fiction: Demaree seems to believe that today, low-income folks don’t spend anything on health care—there just isn’t enough “left over” after they pay for food and shelter to shell out $2,000 for healthcare.

A fair share of those in this income bracket are uninsured. Others have “junk insurance” and are spending $2,000 either because they are paying a high deductible or because they are buying things that they must have and that their insurance doesn’t cover: birth control pills, for example, dental care for their kids, or physical therapy following a serious sports injury or a car accident,

By contrast, under Obamacare, insurers will be required to cover what the ACA describes as “essential benefits” (including rehab after an accident and basic dental and eye care for children), as well as free preventive care (including contraception.)

Demaree is dead wrong when she says that insurance that might cost $1,000 to $2,000 is something that low-income employees “don’t want.”

They are already laying out $2,000, and know that they are getting poor value for their dollars.

— Fiction—the story assumes that for a worker earning $21,000, most policies will eat up 9.5% of his income, or roughly $2,000. The reporter overlooks the fact that employers typically pay at least 2/3 of the premium.

As a result, the average worker at a small firm kicked in just $1,100 a year. At a large corporation he paid $858. For the hypothetical employee earning $21,000, that’s less than 5% of his salary—not 9.6%

His contribution would rise to $2,000 only if premiums for individual coverage shot up from $5,600 to $8,000 a year. This is highly unlikely.

— Fiction: Under Obamacare insurance will be far more expensive than it is today because the ACA insists that policies sold to individuals and small businesses must offer such a rich package of “essential benefits.

Moreover, Obamacare’s critics point out, under the ACA’s rules, insurers will not be able to cap how much they pay out in a given year or over a lifetime. Finally, they must cover anyone suffering from a pre-existing condition without charging them more. Inevitably, premiums will skyrocket and employees will be asked to contribute significantly more than they do today.

This is because large corporations already cover employees suffering from pre-existing conditions without asking them to pay more, and the vast majority include the ACA’s 10 “essential benefits” in their insurance packages. (For example, even before Congress passed the ACA, the law required that companies with 15 or more workers who offered health benefits must include maternity care in their coverage.)

By contrast, today small companies often offer bare-bones policies that limits benefits, and cap how much the insurer will pay out. Beginning in 2014, those that have more than 50 full-time works will have to offer benefits that meet the requirements of Obamacare (or pay stiff penalties.)

Won’t tha automatically lead to steeper premiums for small businesses?

Not necessarily.

The fear-mongers purposefully ignore off-setting factors that will put downward pressure on premiums.

1)Beginning in 2014,companies with fewer than 100 employeeswill be able to purchase insurance in the SHOP exchanges—marketplaces designed specifically for small firms. There, they will become part of a large group, and this means that they will be eligible for lower large-group rates. (Because the administrative costs of hand-selling policies to small groups, and enrolling and dis-enrolling customers are higher, insurers charge them much more.)

2) A company with fewer than 50 employees is not required to offer health insurance. But if a very small businesses want to offer health benefits—and today many are struggling to do just that—the ACA will help them. In 2014, firms with fewer than 25 full-time equivalent employees (based on the number of hours they work each month), and average salaries of $50,000 or less,will be eligible for a tax credit equal to as much as 50% of the amount the employer lays out for insurance. To receive the tax credit, employers must cover half the cost of a single (not family) policy. Experience show that most small business owners already pay more than half of the premium.

3) In the SHOP exchanges insurers will no longer be able to charge small groups higher rates because many of the company’s employees are women, or are suffering from pre-existing conditions.

4) Under the ACA’s “80/20”rule insurers will no longer be free to charge whatever they wish. Insurance companies will have to show that, when insuring a small group, they spent at least 80% of premiums on medical care, and no more than 20% on “overhead” (fees to insurance brokers and agents, investments in offices, salaries for top executives, marketing, advertising and profits for investors.)

Often, this is all of the care that a relatively young and healthy worker will need.

An employee will face a deductible only if he is sick or injured. Even then, if he needs to see a doctor to treat an infection or check for Strep throat,” he may pay $150 to $200—not $3,000.

He will pay the entire $3,000 deductible only if he becomes very sick or needs to be hospitalized. But in that case, if he didn’t have Obamacare, his share of the bill would almost certainly be much higher.Skimpy insurance policies often ask the patient to pay 20% to 30% of a hospital bill. If the patient’s hospital stay is extended he can easily wind up owing tens of thousands of dollars.

By contrast, under the ACA total cost-sharing (co-pays plus the deductible) is capped at $6,500—even if a patient is hospitalized for weeks.

It is true that only Americans who are self-employed, unemployed, or work for a company that doesn’t offer health benefits will be able to go to an Exchangewhere they will be able to buy their own insurance. There, if they earn less than $46,020 ($93,700 for a family of four), they will receive government subsidies to help pay the premiums.

Employees who have health benefits at work won’t have the option of shopping for insurance in these individual Exchanges and won’t be eligible for the subsidies. If they work for a small company with fewer than 100 employees, they or their employer will be able to select plans from the separate small business (SHOP) Exchanges. But in the SHOP Exchanges the government will not be offering subsidies to employees.

This, however, is not an unintended “glitch” or “wrinkle” in the law.

—Facts: The tax credits were intentionally earmarked for middle-income and low-income individuals who must buy their own insurance and pay the full pemium themselves,

By contrast, employees who have health benefits at work already are subsidized by their employers. As noted, on average, those subsidies cover 65% to 75% of the premium.

Congress realized that if employees who could get benefits at work went to the individual Exchanges looking for an even better deal, taxpayers would foot the bill for additional government subsidies.

The architects of the ACA wanted to make sure that health care reform would not require tax increases for the middle-class. (Otherwise, the legislation never would have passed.)

What About Retail and Restaurant Chains?

These large chains won’t enjoy the advantages of purchasing insurance in the SHOP Exchanges for businesses that have fewer than 100 employees.

If they buy comprehensive coverage for their employees, the 85/15 rule will help. Beacause large chains represent a large group of employees, insurers will have to show that they are spending 85% of premiums on medical care, or rebate the difference.

But that is about the only way that the ACA might lower a chain’s premiums.

Obamacare’s opponents argue that these chains will avoid penalties by simply cutting workers’ hours. Reform legislation doesn’t require that they insure part-time workers who work less than 30 hours a week.

But the argument ignores why businesses offer insurance. They have learned that if they offer health benefits, they can attact and retain better employees.

Meanwhile,reserach reveals that if they provide health insurance, they wil be in a better position to hold onto good workers. In the fast-food business,, employee turnover is a major problem; training new employees to cook and provide swift cutomers service becomes a major cost.

Large chains could use healthcare reform to build a stronger business.

97 thoughts on “Obamacare: In 2014 Will Workers Be Able to Afford the Health Benefits Their Employers Offer?”

Yes. Look at the rates in California and Oregon. For $2,000 to $4,000 you can buy extremely comprehsnive coverage that gives you
real protection. Preventive care is free. Children get dental and vision care. Your total out-of-pocket spending is capped ($6,000 for an individual policy) For a median-income individual, that’s 4% to 6%-7% of his income. For $4,000 he gets a gold or platinum plans with very low co-pays and deductibles. If you’re older and expect to see specialists, take medications, undergo tests, might eve be hospitalized, that’s probably the plan you want. It will give you great peace of mind. If you’re 30, healthy and don’t expect to get pregant, the $2,000 plan would probably be fine. (If you see a doctor once or twice a year for something that is not preventive care, and have a co-pay, even a $50 co-pay would be affordable once or twice. And the cap on total out-of-pocket spending means you don’t have to worry about bills that will wipe you out if you’re in a bad car accident. It’s all about peace of mind. And by paying into the pool, you’re buying peace of mind for your mother, your younger brother (a lousy driver who drives too fast, his asthmatic daughter–etc.

Finally, keep in mind that in much of Western Europe, families routinely spend 9% of their income on healthcare (mainly through taxes). But this gives them close to cradle to grave protection. Seniors don’t have to choose between buying food and buying medicine. Children don’t go without care. Mothers don’t go without pre-natal care.
They live longer (partially because of better chronic disease management and more preventive care, partially because there’s less poverty).
Because we are accustomed to employer-sponosred insurance, many of us don’t expect to spend even , say, 6% of our income on health care. (OF course because our employers spend so much on our healthcare, our wages are lower than they might be otherwise–but we’re not aware of that.)
Meanwhile, we spend a much higher percentage of our income than most middle-income Europeans on eating out, ordering in, clothes (more shoes, sneakers, t-shirts– ourclosets overflow), junk food, and toys for our children. .
Compulsive consumption is something we learned long ago.
We also spend more furnishing our homes (and here I’m comparing middle-class Americans to middle-class Europeans); we buy more gadgets, etc.
In the post I cite the BLS survey on consuer expenditures. Go to the website. It’s fascinating to see how low-income, middle-income, upper-middle-income and upper-income people spend their money.

How marvelous of you to let us all know that they way we spend our money compared to Europeans is so ridiculously self-indulgent and over the top, and that for the good of those who don’t work to better themselves, or don’t work at all, or enter this country illegally, I should curtail furnishing my home or buying new shoes for myself as a reward for the hard work I DO.
Incidentally, my couch is over a decade old and I own one pair, exactly one pair, of sneakers. My closet is not overflowing, and I pay a lot more than 6% of my very low middle class income in medical expenses due to cancer. I have curtailed my life style to make sure I can cover my medical expenses, and I don’t have any credit cards. I haven’t taken a vacation in over 7 years, I don’t travel, and now I work from home to curtail the costs of commuting.
Explain to me again why exactly I am a gluttonous, greedy, selfish dredge upon society because I don’t think I should have to pay for any one else’s healthcare?

I understand why you are so angry. You have been diagnosed with cancer, a frightening, painful disease.

From what I say I take it that you are employed (“I work from home”) If your employer offers health insurance he now will have to make it even better. By 2015 they have to cover all essential benefits, cap out of pocket spending (because you are “lower-middle income” your cap will be lower than most), and perhaps best of all for a cancer patient, the insurance company cannot set a limit on how much they will pay out for your treatment in any given year or over the course of your lifetime.

Next year, if your employer is not yet offering the comprehensive affordable insurance that the law says he must offer by 2015 (or pay a penalty) you are entitled to go to your state “Exchange”-an online marketplace where you will be able to buy your own insurance with the help of a rich subsidy from the government. All of the policies sold in the Exchanges are required to meet the rules I list above.

Here’s the bottom line– Under Obamacare you are not being asked to pay for other people’s health care. Other people will be helping to pay for your healthcare. (Wealthy Americans, with income over $200,000 a year ($250,000 joint) will be paying higher taxes to help fund Obamacare.
You are the person with Cancer– an expensive disease–and you will wind up getting much more out of the system than you put in.

That’s what universal health care is all about. All of us in the pool together, sharing the risks that any one of us could be diagnosed with cancer tomorrow.

We just got our new Obamacare plan. Last year we had a top notch plan through my wife’s school. This year we have a very limited network and we were just notified that our local hospital is refusing to accept our blue cross plan. Our plan went up $150 a month and we now have a $4,000 deductible.

Our plan is now terrible. We now have $6,000 less to spend all to give more Obama Voters free stuff. Democrats screw up everything they touch.

You need to Shop for a plan that meets your needs. You don’t have to have a $4,000 deductible. (I have a plant that I bought on the New York Exchange that has a Zero deductible and
very low co-pays. And, next year my plan’s premiums are going down 10%. It has a closed network of doctors and hospitals but all of the doctors I see are in the network and all of the hospitals that I would consider using are in the network. When you have a wide choice of plans, shopping takes time, but is worth it.

I find (through experience) that people who don’t like Obamacare as a matter of principle don’t spend the time shopping. Then they say things like “The only plan I can find has a
$4,000 deductible.

If you tell me where you live, your zip code, your age, the number of adults and children that you are issuing on your plan and your priorities (low out of pocket costs, or particular hospitals or doctors
in your network) I can probably find a plan that you will like much better. If you tell me your joint income, I can also tell you whether you are eligible for a subsidy–and how much
it will be.

I hope you realize that the plan you had through your wife’s school was subsidized by the school. They paid part of the premium. (If she worked at the school, her salary was that much lower because they were paying for part of her and your healthcare. If she was a student, her tuition was that much higher because they were subsidizing her (and your)
health care. Nothing is free.

AS I wrote in a recent blog post, when people who have Exchange insurance are asked how they like it
the vast majority call it “excellent to very good” and “a good value for the money.”

I am a 60 year old single female with no children at home and am not eligible for Medicaid. I make minimum wage and if I applied for the obamacare coverage the least monthly fee wd b a little over $200 per month. After rent, utilities, auto pmt, auto insurance, food I have $50 a month left. I cannot afford any insurance they offer.

I don’t know where you live, so I can’t check whether $200 –after subsidies — is accurate. But I am quite sure it isn’t.
I’m looking at a table of what insurance will cost a 60-year-old, after subsidies in 16 states and I see that the prices range from zero (in Hartford Ct.) to $140 in Sioux Falls South Dakota. In many places monthly premiums for a 60-year-old, after subsidies are $16, $11, $29, $40 etc.
In NYC a 60-year old would pay $111–after the subsidy..
It seems unlikely that you live someplace where insurance is nearly twice as expensive as it is in New York City.
People who oppose Obamacare are going to be spreading a great deal of false information, hoping to discourage people like you so that you don’t sign up for insurance.
You cannot believe what you hear on television or in the newspaper.
The only reliable source of information is your state Exchange.
If you email me and tell me where you live, I’ll try to send you information on contacting your Exchange.
You might want to wait until next week before calling them– today they will be very busy. Give them a little time to get organized.
Finally, when you talk to them ask for the price of the least expensive Bronze plan–after applying the subsidy.
You also will probably qualify for a cap on your total out of pocket expenses–that is called a cost-sharing subsidy.

Maggie, where do you find all this info on exchanges and general help for people who can’t afford obamacare when they look at it online? My son has a wife and 4 kids and his profession was hit hard in the recession we are still in. He no longer qualifies for state insurance, the kids do for this year then the oldest is kicked off it, and he and the wife can’t afford the lowest junk obama plan offered at $300 a month, or 3600 a year?

First, the Exchanges don’t offer “junk insurance.” All policies sold in the Exchanges must cover all essential benefits, offer free preventive care (over 60 products and services) and cap total out-of-pocket spending. For help finding a plan he should contact https://localhelp.healthcare.gov/

No under the ACA, if you are single, you are eligible for Medicaid only if you earn less than $14, 856.
But people earning $20,000 will get subsidies in the form of tax credits.
(Even if they have lost their full-time jobs, are working part-time and don’t owe taxes (because they have children and other deductions) they will receive a check from the government equalling the credit they would have received if they owed taxes.. This also applies to people who are totally unemployed and haven’t been able to find any work.
Finally , expanded Medicaid already has been approved in a majority of states (See http://obamacarefacts.com/obamacares-medicaid-expansion.php)
By the spring of 2014, my guess is that it will be approved in 45 states–or morel

The more significant affordability issue here relates to employees who need family coverage. Affordable employer coverage is defined by the ACA as an employee contribution of less than 9.5% of income for SINGLE coverage. If he needs family coverage and can’t afford the much higher required employee contribution, his family members will remain uninsured and he will not qualify for subsidies to help purchase a family policy and will not be eligible to use the exchanges. Depending on his income level, any children in the family may qualify for insurance under the state’s CHIP.

Regarding preventive care more generally, while it may help people to live longer and healthier lives, it is grossly oversold as a cost saver for the healthcare system. When I think back to some of the big ticket medical episodes that I and some of my colleagues went through over the last 20 years or so, they include surgical procedures such as gall bladder and appendix removal, shoulder surgery, a sophisticated hearing and balance related surgery and my own CABG and DES. Everyone of these patients ranged from outwardly healthy to extremely fit. None were overweight and none smoked. Go figure.

Barry–
Let me suggest that you look at the rates for family plans in teh Exchanges.
Then look at the subsides for families of three, four and five. (Middle class and even people on upper-middle-class
border will be eligible for these subsidies.)
Family rates are actually a better deal than indvidual rates because kids are usuallly cheap to insure and use a great deal of preventive
care (immunizations, which will be free, contraception for teen-agers–free, drug counseling for teen-agers, free dental and vision care for kids, and care for new-borns and babies–covered with a $12,000 cap on out of pocket spending. If you have ever known someone who had a baby born with problems–in need of neonatal intensive care, surgeries etc., you know how little $12,000 in that context.

People with children will be the first to sign up for the Exchanges. Very few people are willing to risk having their children go without insurance. And many of those families will get subsdies.

On preventive care– it’s not about smoking and weight. (You’re thinking of workplace wellness programs). Preventive care is about making sure children get the shots they need; all women of child-bearing age get the contraception they need, middle-aged adults get blood-pressure checks; everyone who might need it is screened for depression/anxiety; everyone who might need it is screened for domestic abuse (in this case what you’re trying to prevent is death by beating); all women get the support, counseling and equipment they need to breast-feed (this protects both women and children from a range of diseases); all women get pap smears (this could eliminate cervical cancer, as it has in some European countries); everyone has an opporunity to have a colonsocopy at no charge . .

You once indicated that you developed heart problems when working in an extremely stressful job. If you had been evaluated for depression/anxixety and had received counseling, you might have decided to move to a less stressful job much earlier in your career.d
Would that have meant that you wouldn’t have had at least some cardiac problems? Probably there is no way to know.

But the fact that you and a number of colleagues who were thin, didn’t smoke and were seemingly healthy ran into some significant health problems suggests that stress may well have been a factor. We know it’s a major cause (or contributing cause) of a great many diseases.
Along with substance abuse and smoking, being a workaholic also constitues a form of self-abuse. ( I know from experience.)

Sorry, I just had to interject, re: you comment about screening for depression/anxiety. It makes me laugh to think that you can really suggest that if this woman had been “screened” she would have learned that she needed to change to a less stressful job. GENIUS! I’m sure this person couldn’t have figured out ON HER OWN that her stressful job was causing her anxiety and depression. I’m sure if she had a viable option for a less stressful job, she’d have made the change on her own, no medical opinion needed. SCREENING is not “medical care” and if people can’t afford the treatment and co-pays, it does no good to be diagnosed.

I don’t know how much medical literature you have read about depression, but often people who are extremely depressed are unaware of it and/or unable to do anything about it. They’re just numb. Very tired.
If someone tells them “You know so & so is hiring”– they can’t pick up the phone.

A professional can tell them You Are Depressed. And perhaps recommend a clinic where they may well be able to get care on a sliding scale.

Alternatively, a professional can recommend that they seek counseling through their church (a rabbi or priest can be helpful, and they won’t charge. Having someone to talk to other than a friend or family can be very helpful. Finally, even if someone cannot afford ongoing counseling or therapy sessons with a psychiatrist or psychologist they may be able to afford the co-pay for generic medication (generic anti-depressants are now widely available and very good.)

What they can’t do is ignore the problem.
Screening is medical care–very important medical care.

Lower paid workers who are deemed to have access to affordable insurance because their employer contribution is less than 9.5% of income will not qualify for a subsidy. While they are presumably free to access an exchange on an unsubsidized basis, it is highly unlikely that they will be able to afford family coverage. I know that some smaller employers allow employees to decline health insurance and add what would have been the employer contribution to the employee’s wage or salary on a pretax basis.

The for-profit insurers will participate in the exchanges on a very selective basis during the first year because they want to gain experience first. CA is one of only seven states that choose health insurers that will be allowed to offer coverage on its exchanges. The other 43 are opting for the clearinghouse model that will allow any insurer to participate as long as the coverage offered complies with the law.

Also, in Southern CA, Kaiser is pricing its offering at the high end of the market. Some say that it is doing this deliberately to ensure that it doesn’t wind up with too many sick people at least until it gains more market experience and confidence. Moreover, it is important to note that the relatively competitive prices being offered in the CA market are not due to tough regulation. They are due to very narrow and limited provider networks.

As I think you pointed out in a prior post, all 13 insurers that will offer products on the CA exchanges will not allow members go to Cedars Sinai. What you didn’t mention is that 12 of the 13 will not allow access to UCLA Medical Center, a well regarded academic medical center but with a culture of aggressive treatment and high prices commensurate with its market power.

There is no free lunch here. Profit vs. non-profit business models have little or nothing to do with this because health insurance is not a very high margin business to begin with and the pretax profit margin difference between for-profit and non-profit insurers is much lower than most people think.

Their employers subsidize their insurance: small companies pay an average of 65% of premiums; large companies pay 75%.
This leaves the worker paying 25% to 35%. Now many more small companies will be able to do this because in the SHOP Exchanges they will automatically become part of a large group, eligible for large group rates (18% lower than small group rates, on average) and insurers won’t be able to gouge them if many of their workers are women, suffer from pre-existing conditions, etc.

A great number of small firms that don’t offer insurance today are, no suprise, the tiniest–under 25 workers. Under the ACA, the government will subsidize them, paying 50% of their premiums as long as they pay 50% of their employees’ premiums. No dobut some will pay a higher share. As more small firms learn about this, more will join the program. They’ll also be able to deduct the half of the premiums that the govt is not picking up. And they can carry that deduction forward or backward. All in all a very good deal.

And a state like California–which is not trying to block Obamacare–will do a good job of getting the word out.

Uninsured families will be quick to pick up the insurance–very few people want to leave their kids at risk. Note that people earning less than $20,000 a year already spend $2,000 a year on health care–often out of pocket.

It may take time to reach some of these familes (those who don’t speak English etc.) but Kaiser and others already are reaching out. (No, Kaiser does not shun poor patients. It has been a leader in Medicaid care. (It’s Hawaii Medicaid plan ranks No. 1 in the nation.)

On networks: Cedars Sinai has a very bad reputation when it comes to patient safety. UCLA is at the top of the list when it comes to
overtreatment. (I guess that is what you mean about an aggressive medical culture.)

I had a friend who was a surgeon there–a brilliant young man who passed the boards in many specialities, just for fun.
Ultimately, he committed suicide. after three tries.
UCLA is a highly aggressive, competitive, money-driven place. Clearly, he was not happy there.
Money and power came first; patients came last.

If you look at quality studies you will find that not having Cedars Sina or UCLA in your network is not a great loss. Quite the opposite.

The difference between non-profit and for-profit insurers is not about margins (you are right for-profit insurers administrative costs are not that much higher than nonprofits administrative costs– super-high exec compensation, and profits for investors are only a small
part of admin. costs.)

The difference is in the culture. Talk to Wendell Potter (who worked in the for-profit insurance industry for many years.) Recently, I have gotten to know him.

The best non-profits (I think of Group Health Cooperative (GHC) in Seattle, Kaiser, Harvard Pilgrim etc. etc. etc.) actually are patient-centered. I spent a couple of afternoons talking to docs at GHC some weeks ago. It is a very good place to work, docs told me, because GHC
focuses on making work “meaningful” Doctors and nurses know that they are working in a system where they can actually help patients.
They don’t feelt the frustration that so many docs and nurses do in other settings.

They are both the insurer and the provider and they have one goal: to keep patients healthy.
There preventive care is excellent. (The number of people who apply to do a residency there in primary care far exceeds the number of places. And most stay–if they are invited to stay.) There is little or no “physician burnout” or “doctor rage” at GHC. They are produ of what they do. As one doc said “It’s good to be us.”
A few years ago they decided to do away with financial bonuses for performance. The doctors I talked to thought this was a good decision.

They have an excellent IT system which works very well. They give doctors time to learn it. (They are paid the same salary whether they are caring of patients or learning the IT. There isn’t the same pressure to see as many paitents as possible. They practice tele-medicine and e-medicine. Medicare patients, in particular, love it. (They don’t have to get on a bus or find parking when they want to refill a
routine prescription.) When they do come in, a doctor may well spend 30 minutes or 45 minutes with them.

It’s all so rational.

IF you talk to Kaiser’s George Halverson, you will find that he, too, is an extremely enlightened administrator.

The culture at Aetna and Cigna is very very different. (I covered the big insurers when I was at Barron’s. So much corruption.
And they completely screwed up managed care. Originally, it was an excellent idea–evidence-based medicine with an emphasis on keeping people well. Insurers were supposed to refuse to cover ineffective care. But instead of comparing treatments based on whether they were effective, they focused on how much they cost, and refused to cover if very expensive.)

Kaiser, by contrast, has always kept its own data-base so that it can see what is effective and what isn’t. It practices evidence-based medicine and it’s a team approach. Lone Rangers can’t just do their own thing.

Its hospitals provide the best care in many states (Again, see quality assessments that take a multi-pronged approach.)
Patients stay with Kaiser for generations. Doctor turnover is very low.

No Kaiser is not the cheapest insurance in the Exchange. But people will buy it because they know that it’s better. (It’s reputation in California is very, very high, both in S. Cal and in N. California. AS you know, Kaiser has reduced heart disease fatalities in N. Calfornia dramtically. This is all about chronic disease management, preventive care, free smoking cessation programs. . . .

For the record, the health issue that was the catalyst for my leaving my former high stress job had nothing to do with heart disease. Evidence of heart disease did not surface until three years later and it was another three years after that when a CABG became necessary. By that time, I was six years into a job at a place with a highly collegial culture that believed in work-life balance and the nicest most decent colleagues you will find anywhere. By Wall Street standards, that’s as good as it gets and the compensation was more than adequate to boot.

Stress is part of life in America, especially in NYC and especially in the financial services industry. It comes with the territory. Also, stress comes in many forms much of it unrelated to work. Commutes can be long. Marriages can be rocky. Kids can be tough to deal with. Travel schedules can be onerous. Parents can be in failing health and need support.

Maybe Europeans and Canadians have lower expectations in terms of housing, cars, boats, and other material goods than Americans. They value leisure more highly. They are willing to pay much higher taxes to support a more comprehensive social safety net. It’s a different mindset, culture and value system. We’re not them and they’re not us and it’s always likely to be that way no matter how much the left would like to make the U.S. more like Europe including the much higher taxes on the middle class and wealthy needed to support their societal model.

WE pay a very high price for our more materialistic culture (expectations in terms of housing, carse, boats and other material goods.)
Rates of mental illness are much higher in the U.S. Rates of teen suicide are higher.

Many Europeans I know have lovely homes (not as large as ours), gardens (not terribly expensive and often beautifiul)
beautiful clothes (just not as many–though often of higher quality) take many vacations (often within Europe, so travel costs are low).
They don’t spend nearly as much on cars. (See their relatively new, very tiny cars.) Because oil prices/gasoline has always been more costly in Europe they learned fuel conservation long ago.)

Could Americans become more “European” in certain ways?

We are still a young country. Europe is much older, and parts of Europe are far more civilized.

Over time, we may grow up. (Or as Obama said when he was elected: “The time has come to put childish things away.)

Certainly, New York City and L.A. are outliers– extreme versions of U.S. culture.

New York is a city that is all about money. L.A. is a city that is all about entertainment/glamour, appearances.

There are, I would argue, more civilized parts of the U.S. in the Northwest (which many lefties of my generation went after
graduating from college), some places in the South (I think of North Carolina-) some places in northern New England (Hanover, New
Hampshire, for instance. The hospital there– Dartmouth/Hitchcock– is so very different from New York’s large academic medical centers. . .

Perhaps, eventually, we’ll learn from these places. When it comes to healthcare, we’re already beginning to learn from the Northwest and Northern New England where the medical culture is very different. Particuarly in the NorthWEst and upper Middle West–docs on salary, more co-ordinated care, physicians and nurses working in teams, more people want to practice primary care . . .

Up to about 10-12 years ago it was almost automatic that if an employer offered health insurance, then they offered family health insurance for workers with dependents.

I think this is still true in government plans and union plans.

I wonder how many other employers have gone to the model of paying for the worker only and not dependents?

I myself worked for such an employer. I had to buy a separate individual policy for my wife and one young adult child. It was a repulsive high-deductible piece of crap —
$600 a month premium for a $5500 deductible.

The decision by the Administration to use the narrow definition of affordable coverage was a real anti-worker move in my opinion. It saved money on the cost of the exchanges — a very cowardly approach in my view.

Incidentally, Barry, on your last point about America vs Europe. You are correct about the phenomena of leisure and high taxes in Europe, vs. more work and lower taxes in America. My only addition to your comments is that I do not think this has developed from any “national preference”.
You and other commentators sometimes make it sound as though Europeans and Americans held some kind of straw vote on their lives.

Instead I think that Europe has much stronger labor unions and labor-dominated political parties. These groups pass real laws about work hours and taxes, and they get re-elected (look at France).

America has almost no private sector unions any more and as I comment above, it certainly has no national labor party.
Therefore the amount of leisure you get is a function of who you work for solely.

Under the ACA employers do have to cover children (including adult children up to 26).

But they don’t have to cover spouses.

This is, I think, understandable. Employers are tired to covering wives who, in most cases,
also work. These employers feel that her own employer should cover her.
The husband and wife can then decide whether they would be getting better coverage if the kids were
on her plan or on his plan.

Finally, now, under the ACA, if the spouse doesn’t have coverage at her job, she can go to the indvidual Exchange and get excellent coverage there. She may also get a subsidy, depending on the size of the family and their total income.

On unions in the U.S.– By 1980, Americans had became strongly anti-union. Many resented the fact that auto-workers
and others had good salaries and benefits. Corruption in various union (the Teamsters come to mind) also
turned people off.

Around 1980, Ronald Reagan broke the air-controllers union by laying them off. (What they wanted was simply
more air-controllers on duty at a given time. The pressure was too intense–they were trying to watch too many planes.)

I recall that time. Americans did not support the air-controllers. They applauded REagan’s action. (Some of these men would never work again– their only training was as air-traffic ccontrollers.)

Today, many Americans resent public school teachers and other government employees because they have unions– and benefits.

I’m very glad teachers and govt workers have these benefits, and by and large, they are paid less than they would be in the private sector.
But Barry is right. There has been what is in essence a “straw poll” about unions and Americans don’t like them.

The French are so very different from us politically. Ideologically they still believe in liberty, equalty and fraternity” (the slogan from the French Revolution. OUr revolution was run by wealthy men (landowners) and the slogan was “No Taxation Without Representation>’

We still resent paying taxes— which is why our workers don’t have the social safety nets, vacations, paid materntiy leave, etc.
that many Europeans do.

I know that no reform is perfect, but I can see a worker who earns $50,000 paying up to $4750 as his share of employer coverage; his spouse earns $20,000 so that family income is $70000. His spouse is age 60 (like my spouse) and so she gets maybe a $2000 subsidy on a $6000 policy, leaving her with $4000 out of pocket premiums.

Overall the family is paying $8750 a year or $760 a month for health insurance out of pocket.

On a $70,000 gross income, the after-tax paychecks might total about $5,200 a month.

This is not the fault of the ACA but it is still pretty ugly.

As to the America-Europe distinction……I would suggest that we could have paid maternity leave for about 1% extra in social security taxes ( assuming the government funds the leave, not individual employers)……and we could have longer vacations for no extra taxes whatsoever, if we had unions to insist on longer vacations. Taxes are not entirely the barrier.

Funding it through Social Security taxes would be
extremely regressive. Low-income and middle-income workers pay a far larger share of their income toward Social Security taxes than wealthy families do.

Maternity leave should be funded on a progressive scale–which means higher income taxes for those in the top 10% (households earning over $110,000).

And in most other countries, employers (not the government) are required to offer paid maternity leave.)
(Our laws are written by legislators who receive huge campaign contributions from large employers. In other countries, that is not the case. As a result, corporations are excepted to contribute more to thing the “common good” of the society and the economy.

Moms who have paid maternity leave have a better chance of learning how to become better mothers.
Not only do they have time to breast feed, they have a chance to play with their children, and get to know them at a very early age. These kids also bond with their mothers; when Mom say “No,” they will be much more likely to pay attention.

We all have a vested interest in the future of the nation’s children, if only for purely selfish reasons: we will be depending on them to fund our social security and Medicare.

Bob– regarding your example: You suggest thatt a man earning $50,000 would pay up to $4750 as his share of employer coverage; his spouse earns $20,000 so family income is $70000. His spouse is age 60 and so you say she she gets” maybe a $2000 subsidy on a $6000 policy, leaving her with $4000 out of pocket premiums”.

Take a look at the California and Oregon rates that have been announced..

The total premium for the man (what he and his employer both pay) is not likely to be higher than $5500 (even if he is older.) On average, employers pay 65% to 75%.

This means his share of the premium is about $1500 to $1900– not $4750.

In the Exchange, his wife is likely to pay no more than $4000 –$5,000 for an individual policy.
Subtract the $2,000 subsidy that you calculate that she would owe, and she pays $2,000 to $3,000 (Max)

Add that to his $2,,000 (max) and together they pay $5,000—while earning $70,000.

This is affordable–and well under 9.5% of income. .

(If you look at what Americans earning $70,000 pay for many other things, it becomes clear that that is entirely doable. And they will have peace of mind and long-term protection that they don’t have today. Whatever happens, health care bills won’t bankrupt them or force them to sell their homes. As people get older, and know other people who have wound up with huge medical bills, this is one of their great fears.
The peace of mind is well worth the money.

Regardless of what happens to the price of health insurance in the individual insurance market in the short term as the exchanges go live, I’m actually quite optimistic about our ability to bend the healthcare cost curve over the intermediate to longer term. I’ll highlight several areas of interest.

1. There was bipartisan legislation introduced in Congress to make the Medicare Claims Database available to the public online for free. The bill would specifically include payments to individual providers by name and require that they NOT be subject to protection from disclosure under the Freedom of Information Act (FOIA). This could significantly advance the cause of price transparency and make it easier to identify fraudulent payments within the Medicare program.

2. Dr. Ezekiel Emanuel co authored a report for the left leaning think tank, Center for American Progress, which supports safe harbor protection from lawsuits for doctors that follow evidence based guidelines where they exist. This idea holds tremendous promise, in my opinion, for reducing defensive medicine in connection with the failure to diagnose a patient’s disease or condition. Democrats in Congress need to take on the trial lawyers on this one.

3. Dr. Atul Gawande is in the process of seeking funding from foundations and others to organize a think tank that would tackle the end of life care issue. Medicare is already experiencing a decline in the number of inpatient bed days among dying patients while hospice care and the percentage of patients dying at home is increasing but there is much more work to be done.

4. New payment models that seek to reward value instead of volume could reduce unnecessary care while improving patient safety and lowering preventable hospital readmissions. To help this along, compensation arrangements for doctors need to incorporate these metrics in a meaningful way in structuring bonus compensation.

The Board of Trustees also needs to give much more weight to patient safety and reducing preventable readmissions in determining bonus payments for the hospital CEO, CFO and other appropriate members of senior management and less weight to traditional financial metrics of revenue and profit generation as well as market share growth.

5. On the negative side, hospital consolidation and buying up physician practices is driving up prices per service, test and procedure. The FTC needs to more aggressively look at the anti-trust implications of further hospital consolidation.

Medicare needs to adopt rules that will equalize payment for any outpatient service, test or procedure performed by a hospital owned physician practice or facility and the same care performed by a non-hospital owned physician practice, imaging center or other provider. We need full price and quality transparency as well so both patients and referring doctors can more easily identify the most cost-effective high quality providers in real time so more business can be directed to them.

6. We need special rules that govern what insurers and the uninsured must pay for care delivered under emergency conditions which, by definition, cannot be scheduled in advance. Some appropriate and reasonable percentage above the Medicare rate seems like the best approach to me.

That is exciting about making the Medicare claims database open to the public!

Maggie, I did realize about an hour after I posted that I had made a miscalculation about the insurance premium that one spouse would face. Thanks for your point.

To backtrack a few posts…….I was very impressed that California could produce lower premiums just by excluding the UCLA Medical Center.

I have said for years that premiums are greatly affected when we pursue perfectionist medicine — i.e. spending hundreds of thousands of dollars on one patient. We feel good if a life is saved, but the backwash on premiums is substantial. Arnold Kling is somewhat of a right winger but a good writer, and he makes this point also.

Bob–
A number of good points in the two comments above.
I’ll reply to a number of them later.

For now, just one point:
UCLA is not “perfectionsit medicine”–quite the opposite.

It is less-than-high quality medicine. Overtreatment hurts people. It means operating on people who don’t really need surgery. That’s like operating on the wrong leg.

BETTER HEALTH CARE IS NOT MORE EXPENSIVE HEALTHCARE.

All of the DArtmouth Reserach shows that care at the Mayo Clinic in Minnesota is LESS EXPENSIVE THAN UCLA because they don’t over-treat, they don’t run as many tests (they get the diagnosis right earlier in the process the old-fashioned way: Before running a battery of tests they listen to the patient, take a good patient history and narrow down the list of tests to those that make sense.)
Patients at Mayo spend fewer days in teh hospital and see fewer specialists.
Bottom line: HIGHER QUALITY and LOWER COSTS GO HAND in HAND .
This is what Kling doesn’t understand (or doesn’t want to understand). He believes that when you pay more for
a “brand name hosptial” you get better care. Wrong. Many brand-name hospitals are not patient-centered–they are money-driven.

It’s not just the elimination of access to UCLA Medical Center that accounts for some of the lower premium quotes for policies to be offered on the CA exchanges. According to recent reporting in the Los Angeles Times, Blue Shield of CA, a non-profit insurer, is offering a policy that only allows members to access 36% of the doctors that are in its much broader PPO network. Those policies, of course, are presumably priced considerably higher and include access to the more expensive hospitals as well. All of the exchange offerings are limited network and narrow network insurance products. It doesn’t mean the patient can’t access good care. It just means that there is a lot less provider choice and patients may also have to travel further to reach an in network doctor or hospital neither of which are huge problems in my opinion.

Speaking as someone who was painfully uninsured for a time in the 1990’s, I would have taken a ‘limited network’ over no insurance any day of the week.

Sometimes in US health policy we let the perfect become the enemy of the good. My impression of European health care is that they are willing to forego some types of heroic life-saving care, in order to preserve primary care for all and also to preserve social benefits like home visits to the elderly.

The absolutist position on health care is getting impossible to sustain financially.

European countries don’t let people die because it would be too expensive to keep them alive.

They, too, do organ tranplants and other very expensive procedures.
(Only the UK limits care based on cost.)

But doctors in Europe are much less likely to hold out false hopes. In most cases, neither they or the hospitals are going to make more money by persuading patients (or their families) that the patient should go through another round of futile treatment.

But the U.S. can and should continue to offer heroic life-saving care when there is at least a fair chance that it will help. We can afford to do that and to offer excellent preventive care, and more importantly, chronic disease management– as long as we begin to cut out the waste. Keep in mind that today 1/3 of health care dollars are squandered on tests and treatments that do no good. This includes preventive care such as “executive physicals,” PSA testing, many mammograms, many cancer screenings. One-half of angiolplasties do no good (and we know which half), a large share of back surgeries are pointless, we do Way too many C-sections, we pay far too much for many drugs and devices. (I’m hopeful the govt will begin to regulate those prices in coming years– just like virtually every country in the developed world. )

Finally, you’re right that narrower networks are not necessarily a bad thing. In many cases, the providers that are being excluded are not better– they just charge more and so laymen think they are better.

Bob, the “absolutist” position on health care in the US means treat, treat, treat all the way until the patient is so dead the corpse is black from lack of oxygen.

As Maggie has often pointed out, Medicare spends the most on patients in the last 2 weeks of their lives, usually on futile, painful, invasive “care” that does nothing to benefit the patient or the family, and really doesn’t benefit the doctors or hospitals in the long run.

We need broader adoption of hospice and an understanding that choosing the hospice model does not mean giving up; in fact means the opposite.

Actually, Medicare spends the most in the final two years of a patient’s life.

What is most costly is not end-of-life care, but care for those suffering from chronic diseases that, by definition, last a long time.

In order to pare those costs, the only thing we can do is learn how to do a better job of managing chronic diseases.
When everyone has access to healthcare–and providers are rewarded for keeping patients out of the hospital–this will be easier.

Because end-of-life care in those final days can be so dramatic–and so expensive per day– we assume it consumes most of
our dollars. But end-of-life care lasts only days or weeks–not years. It is the patients who are in and out of the hospital over those
last two years, undergoing surgeries, undergoing chemo, etc. who cost us the most.

Most cancer treatments do not save lives. At best, they extend lives–or prolong the process of dying. In most cases, the patient is led to believe that the treatment will either save his or her life–or extend life for a significant period fo time. Very often, that is just not true.

I believe that doctors are much more reluctant today to do surgery on patients who are near death.

But the costs to Medicare are still high. I suspect that if you study the claim payments, the bulk of costs is just one day after another in intensive care. 20 days in intensive care can cost $80,000 without a single last-ditch surgery of any kind.

To Maggie:

Your observations bring up the delicate issue of marginal gains.

If you interview Americans on the street and ask them if Medicare should pay $100,000 for a treatment that extends life by 12 months, most of them will say yes.

In fact they think that England is heartless for refusing to do this.

I know there are academic studies which show that the US can afford to pay $100,000 per year of life. Something feels wrong about these studies, though I cannot say clearly what I feel. Comments welcome!

If we look at the millions of dollars that affluent Americans spend on homes, automobiles, toys for adults, vacations, food that is left uneaten and thrown away, clothes we never wear, $400 bottles of wine, weddings that start at $200,000, over-priced private schools that, in some cases, are not worth the money, fauz-art, and millions of dollars worth of ineffective care you will realize that, in fact, we can easily afford $100,000 surgeries–as long as there is a reasonable chance that they will be effective.

At that upper end of our society, too much money is concentrated in too few hands, much money is chasing too few things, and thus everything from over-the-top weddings to McMansions are over-priced.

My husband works for a large employer & it is a union job. We have decent insurance for our family. Hopefully, I will be getting a job making about $32k/year & they will offer insurance. Do I have to take it or can I stay on my husband’s insurance?

Last year our insurance, BCBS Anthem went up $700 for no apparent reason. So, now they do have a reason, what are the chances they could go up again because of Obamacare? This is our contract year & the company has spent millions on new machinery so I don’t think this contract will drag out. Even though we make decent money due to my husband working for a good company and working a LOT of overtime, we still have three college age children and live paycheck to paycheck. I am stressed due to not knowing what to expect.

What if we can’t afford the increase? Do they expect us to pay insurance over our house payment? Our situation may not be this severe, but there may be people in situations like this…

If your husband works for a large employer and you have good insurance, it’s not likely to go up
much. Chances are it is comprehensive coverage that covers all of the things that the Accountable Care Act says insurance must cover (the 10 essential benefits). And it probably caps how much you have to pay out in deductibles and co-pays.

Recently, insurance premiums have been going up about 2 1/2% 3% a year. That’s just inflation– each year doctors, hospitals and drug-makers charge a little more, and so health insurance, like everything else, becomes a little more expensive.

But people are not expecting the 7% to 8% increases of the past.

The foks who will see their premiums rise are those who had bare-bones coverage-or “skinny policies.” Under refrom, insurers are required to offer more comprehensive coverage–and real protection. That, of course, costs more than
cheap policies that really aren’t worth the paper they are written on.

Under the law, you are required to have comprehensive insurance–or pay a penalty. Whether you get it from your employer or your husband’s employer is up to your husband’s employer. Under the reform law, his employer is required to cover his children, but not his spouse.

(Many employers are getting tired of paying for health insurance for someone else’s employee. (They feel– why should her boss save money while I carry her? She doesn’t work for me?)
So it is possible that if you have another way to get insurance, your husband’s boss won’t cover you. I don’t know whether his union has negotiated coverage for spouses.

But I wouldn’t worry too much– at this point in time, most employers still cover spouses.

Can I suggest that you list the actual benefits that are “covered” under preventable. Cause I have very good insurance, and the MINUTE that this bill went through, they changed how they cover things.

For instance, you can get free blood work, but if your values fall within the acceptable limits, otherwise the bill goes to your coinsurance. Because the way the look at it is, you didn’t “prevent” a disease. I am a Medical Laboratory Scientist, and I can tell you, right around the time this happened, the reference ranges for the test expanded way beyond normal limits. I’m sure this was on purpose, to where you have to be dying in order to get your blood work for free. So about the only thing “preventable” that is covered is certain non-expensive things that can be gotten for free anyway, such as vaccinations and birth control—both of those are available for free from your local clinics–especially if you are so poor you can’t afford birth control (medicaid). I know this for a fact, because my niece got the thing in her arm for absolutely free without insurance.

In addition, almost everything went to co-pay/coinsurance. Meaning, instead you paying 80/20 up to your deductible, now everything is basically co-pay. This includes any screening tests. For example, if you need a colonoscopy, you pay a co-pay that does not apply toward your deductible. Used to be these things were covered and applied to your deductible. This is no longer the case.

i’ve read the legislation too – and i’m telling you – free is never free….just because the patient does not pay a co-pay the day of the service does NOT mean that it’s not built into the price of the policy. I do have hypertension, and i do not see why i need to pay for blood pressure checks, when i have purchased my own cuff, and can get my blood pressure read at any drug store, or even at my employer, already for free. Now with these mandates “free” services, they will be baked into the price of my policy that will not be necessary. Free is never free–someone, somewhere is paying for it.

Insurance is about all of us helping each other. We pool our money to spread risks.
You need to get over thinking in terms of “me”– trying thinking about “we”

Finally other countries have found that, over time, free preventive care reduces the cost of care.
For instance, in some countries in Europe where Pap smears are free, cervical cancer is now non-existent.

Everyone is saving because no one is paying for expensive treatments for women suffering from cervical cancer

In this country, Kaiser Permanente has managed to greatly reduce deaths as a result of heart disease by offering
free preventive care.

Our insurance has gone tripled since 08, and we had to drop our kid’s because we can no longer afford to keep them on it.

One kid opted to work at Walmart because they offer medicare, new high school graduate. The other a waitress who was enrolling in school until she found out that money will go to Obamacare instead.

We were just sent a notice by my husband’s employer to expect another 30% increase when our insurance renews in June 2014 due to …. obamacare. We can’t afford the additional 30%, so we will even drop our insurance(which will likely be the death of me) or have to move out of our house as our insurance will cost more than our tiny house. And rent is just as high as our house, so where do we go?

Your insurance has tripled because doctors and hospitals and drug-makers charge more each year.

This has nothing to do with Obamacare.

Obamacare is trying to bring down medical expenses.

I have a hard time imagining parents who would leave their kids without insurance while insuring themselves–unless one of you is very sick. .

When you say your daughter was going to enroll in school “until she found out that money would go to Obamacare” I have no idea what you mean.

Finally, if your husband’s employer is raising the price of insurance by 30%, this has nothing to do with Obamacare.
Large companies already cover hte benefits that they are required to cover under Obamacare and small companies don’t have to do anything until 2015.

If your husband’s boss is raising your share of the premium by 30% that probably simply means that his business is not doing well and he can no longer afford to pay such a
large share of your premium. (Most employers pay around 70% of employees’ premiums.)

Under Obamacare a bronze plan would probably cost a 20-year-old around $100 a month—significantly less if she lives in a place where insurance is cheaper than average.
That $100 a month would give her free contraception, free Pap smears, OB-gyn exams and other free preventive care.

Subtract what she now spends just on contraception and an annual OB-Gyn visit (assuming she now never goes to a primary care doctor) and she can earn the amount that insurance will cost.

You are right, it is the underlying cost of health care–not the cost of insurance– that is the big problem.

But the Affordable Care Act is designed to bring down the cost of care–and it’s already happening.

Hospital bills are no longer growing at the rate they were– and most of the ACA won’t kick in until Janauary.

As the ACA is implemented, more and more doctors and hospitals will no longer be paid “fee for service”–which encourages doing more (more tests, more procedures etc.)
even if patients don’t need it. About 1/3 of our heath care dollars are squander on unncessary or over-priced products and services.

Under the ACA health care providers will be rewarded if they can deliver better care for less. IF they can’t, many will be penalized. (Medicare, the biggest payer in the nation will pay them less. Insurers will be following Medicare’s lead. Washington also will be cracking down on healthcare fraud (this already as begun). And hospitals will not be
paid for avoidable medical mistakes.

By making better use of tele-medicine and e-medicine we will lower medical bills. (Patients won’t necessarily have to go in to see their doctor to have a prescrption renewed; they will email him or phone him. His nurse practitioner will call in the prescrption.

President Obama has signaled that he plans to bring down the cost of prescription drugs. This means that the U.S. government–like the governments of every other developed nation– will stand up to drug-makers and say, No medicare will not pay twice as much for this new drug. You offer no medical evidence that it is that much better for most people.
We will cover it only for patients who meet a certain medical profile and really need it. And then we will pay only 25% as much–not twice as much.

You have a hard time imagining parents that would insure themselves, but not their kids? What cloud have you been floating about upon? When I was young, my mother and father carried insurance on themselves, but not us…if they got sick or injured and missed work, money didn’t come in. No food on the table. Repossessed car. Foreclosure on the home. You know? We kids weren’t allowed to go skiing or do other dangerous activities likely to cause injury. Sucks? You bet. It is called reality…many of us live it.

I grew up in a working class family–working class welfare class neighborhood. But I never knew parents
who would insure themselves and not their kids. Most people put their children’s health ahead of their own.

I’m reading this and seeing interesting “what’s suppose to be” information. Unfortunately what is actually happening is that California teachers are taking a HUGE cut in pay hit because of Obamacare. Although many may be anti union, California teachers who do not make a lot of money in most cases, but receive good health care for ourselves and our families as an offset to not great pay. Now we are having to pay 100.00 per person in our families per month to get a “lesser” quality of insurance. For a family of four that’s a 4,800 a year pay cut on a teacher who has worked 15 years and making maybe 60,000 a year. Unfortunately teachers along with police, fire and nursing in general are the middle class. The same thing is happening across the board to all of these service workers. And yes in some places these types of employees are overpaid but the reality is that the few “abusers” do not make up the majority. Regardless how you look at this situation, the reality is that Obamacare is hurting the middle class and many are saving rather than spending and looking for more ways to save since the further seems to be getting worse not better. When my family has to choose between my child being able to pay to play AYSO soccer or go out once a week to eat dinner, to put money away for retirement or buy a needed car, to go on vacation or support local charities… Something has to give and and it hurts everyone in the big picture: businesses, community services and more. These are the types of choices the educated middle class are having to make and it is slowing the economy, not supporting it. Obamacare sounded good but now has caused even more hardship on the working middle class. What happened to a shared burden for everyone? To me it seems like because we have done the right thing, not spent more money than we should on housing, not maxing out our credit cards, saving for retirement and education, we seem to get nothing but having to carry a higher share of the burden. We know people that have lived beyond their means and are now getting “relief” from the government or lost a job in an industry that was taking advantage of others and are still get “relief” from the government 4 years later! It’s disgusting, since that “relief” comes from the taxes we diligently pay. We are actually looking at a few other countries since my husband is a civil engineer and these types of jobs are needed all over the world and becoming ex pats. We dont believe our 11 and 6 year old have a real possibility of living a quality middle class life in the United States. In many other countries at least they are upfront and honest about extortion and abuse. In the US we “dog and pony” it and just pretend. You can say what you want, but I’m living the current Obamacare problems and its not what it’s suppose to be… It’s a nightmare.

Incomes are higher in Northern California than in any other part of the state.
In N.Cal. Median income is $44,600. Half of your fellow Californians earn less, half earn more.
In other parts of the sate, median income is much lower.

I don’t know where you live, but if you’re earning $60,000 you are ‘upper-median income” or upper-middle class.

Plus you will be getting health insurance for just $1200 a month. I realize that in the past you had free health insurance, and got used to it.
But most people have to pay for their health insurance.

You mention that a family of 4 would have to pay $4800 for health insurance. ($100 per person per month.)

In a family of four there would probably be two adults working. If you are in a family of four and your husband works, earning as much as you do,
your household probably is earning $120,000. IN 2012, median income nationaiwde was about $51,000. A family for four earning $120,000

So if you are married to someone works you are not even close to middle-class.

I hope this puts things in perspective.

Even if you are single and have only your $60,000 income you are doing better than most Americans.
And health insurance for $1200 a year is a very good deal.

By the way, my daughter is a public school teacher in NYC and makes less than you do. I know it’s a hard job, and I admire people who do it.

Oh and by the way before you think 60,000 a year is a lot in California, consider gas costs over 4.09 a gallon, milk cost 4.00 a gallon, rent in my city is approx 2,800 a month for a 50 year old 1,000 square foot 3 bedroom house, that same house costs 780,000 to buy. Property taxes, state taxes and insurance fees are some of the highest in the country and that doesn’t include federal. Ironically groceries here often are more expensive that that in the Hawaiian Islands. Before you consider that someone is “overpaid” look at the salary in conjunction to the cost of living of an area.

I would hope that after earning a BS and a MS that I would be doing a little better than the average, but again I live in Orange County which is very expensive sales tax is 8%. You did not address additional costs Californians pay in property taxes at 100% value of home. car insurance (5th highest – New York was 22nd I think ) and state taxes 9.3% compared to say NY 6.65% and on and on… Basically you’re giving me a pat in the back saying I’m better off than most but you are not comparing apples to apples. It’s more like oranges to apples. With
your background I expected a more knowledgeable take. Yes I could move but at this point on the pay scale I can not afford to start over somewhere else. You did not address the 4,800 pay cut that health care “reform” has caused my family. So I must sacrifice for the good of the whole huh? Interesting. Well I hope when this reality happens to you and your family that you think this is still a wonderful plan. I have a feeling you will no longer be championing it. Obamacare was not well thought out or thought through. I believe its heart was in the right place upon creation, but the damaged bill that is going through is destructive. It is already damaging the middle class in California. And just wait until it hits hospitals ( we have two friends who are doctors and highly concerned how hospitals will be affected-so far hasn’t done anything to either of their practices). I expected a more informed take and usage of facts other than median salary comparison which means nothing unless you take into consideration things discussed above. I’m not complaining just discussing the facts that I had a 4,800 pay cut thanks to Obamacare. This isn’t a scare tactic, this is what has actually happened to me and almost all teachers throughout California in the past two years thanks to Obamacare. I hope your readers choose to check the actual facts that are currently hurting real people rather than what is suppose to happen.

It doesn’t change the fact that by June 2014 that my husband and I will have to drop our insurance and pay the fine. And I’m the only one who uses it and dropping it will likely be the death of me. Or we could just get divorced and I can go on welfare, medicaid and just game the system like everyone else. But hey, as long as it’s affordable. Just keep on telling people it’s not obamacare, when before obamacare, the cost of insurance was stable.

I currently have an individual group policy with Blue Cross and pay $155 per month; I have now been advised that under the new “affordable” care act my premiums will more than double for the lowest plan they offer and go to $308 eff. January 1st. (Bronze), and deductible goes from $5000 to $6000. I am not eligible for any kind of premium reduction or tax credit off that rate because I am above the poverty line, and I work for a company who offers health insurance. The premium thru the company is $100 more per month than I am paying now ($250) which is one of the reasons I have had individual group policies thru Blue Cross as about 10 million other people do nationwide (with them) as their rate has always been lower than the company rate.

The simple question is: is this true that their are no lower rates available (health cost credits) if your income is above the poverty line and the company you work for already offers health insurance?

What about the fact that this $250 new figure is more than 9% of my gross annual income if I elected to accept the company insurance? One person told me does not matter as that provision regarding credits on that won’t kick in until 2015; the other said I might be entitled to a credit for the portion over 9% but kind of hard to determine because I am not under that company insurance plan now.

Anyone have any definitive answers or suggestions on how to proceed? Already spoke to Blue Cross but did not get the answer sought there. Thanks!

First, you don’t have to below the federal poverty line to be eligible for a subsidy.

If you are single and earn somewhere between roughly $11,000 and $46,000 a year you qualify for a subsidy to help buy premiums.

You also may well qualify for a “cost-sharing subsidy” that will lower your co-pays and deductibles. To get answers to all of your questions go to your state’s Exchange (or marketplace where you can purchase insurance find out about subsidies.

Do not listen to what ANYONE ELSE tells you about insurance. Two-thirds of the information out there is wrong.

Finally, if your company offers insurance that is not affordable (it costs more than 9.5% of your income) or is not comprehensive (it does not pay for 60% of covered benefits)–you will be eligible for a subsidy in the Exchanges (assuming your income is below the threshhold.)

Just checked the exchanges and if you make less than 15k per year, the Bronze plan is fully subsdized in SC. However, with a $5000 deductible + 40% co-pay, you still can’t afford to go to the doctor. Obamacare doesn’t really help those who can’t afford insurance. All it does is transfer money from the U.S. Treasury directly into the coffers of the Insurance companies, the same companies who were instrumental in writing the law.

If South Carolina expanded Medicaid to include everyone who earns less than $15,282 — as they are supposed to do under Obamacare– you would be eligible for Medicaid.

Medicaid is free.

The problem is not Obamacare– it is South Carolina. (Under Obamacare the federal govt pays for almost all of the Medicaid expansion. But South CArolina politicians refuse to do it–purely for political reasons.

Next time you vote, vote out the South Carolina politicians who refused to expand Medicaid.

Secondly, did you know that under Obamacare preventive care is FREE? No co-pay and no deductible. This is true for all plans sold in the Exchanges. So if you go to your doctor for preventive care, you pay NOTHING>

If you go to him for something else you would pay no more then 40% of his bill.
unless you are in poor health, it is very unlikely that you will ever pay the $5,000 deductible.

For example, let’s say you go to the doctor for something other than preventive care, and he charges $150. . If your co-pays is 40%, you pay $60. If you go to the doctor three times during the year for something other than preventive care, and he charges $150 each time, you pay a total of $180.

And you monthly premium is ZERO. This is a very, very good deal.

If you are hospitalized, you could wind up paying the $5,000 deduciible plus co-pays that take your total out of pocket spending to $6,350–max.. After that your insurer pays all bills.

IF you are not in good health and think you might need hospital care–or expensive treatments– then you should use your subsidy to buy a silver plan. Chances are you’ll have a small monthly premiums (after the subsidy) but your total out-of-pocket spending could be capped at 1/4 of $6350 or a little under $1600. (that’s co-pays and deductible.) The cap depends on how low your income is.

But you get this lower cap ONLY if you buy a silver plan. Still, for someone who is going to need quite a bit of medical care, it is a very good deal.

Well I am one of the devils. I am an RN who started his own healthcare company 15 years ago and now have 800 full time employees. I pay 75% and employees pay 25% and our rate is around 400.00. Last year I had 400 employees who took the coverage. About 200 are on their spouses coverage and about 200 are what I call the 23 year old male employee who thinks he wont get sick (he probably wont) and does not want to pay the $100. I use all that savings to subsidize the cost of the 400 that take it. Next year when everyone must take it I will charge everyone 9.5% of their pay to cover this. So who is getting screwed here…ME? No The employees get it once again. They used to be able to work 10-12 hours too but that was exploitive so now they just get 8…Lucky them.

You should be able to get a better price because in the Exchange you will be part of a Very Large group. This means administrative costs will be lower for the insurer–and as part of a very large group, you will have more leverage.

I understand that you save $300 on each employee who doesn’t take insurance. So perhaps under Obamacare, you will have to ask them to pay a little more than $100. But 9.5% of their income seems unlikely. (Lets say your average employee earns $30,000. 9.5% would be close to $3000 a year. I cannot imagine that they will need to pay nearly that much . . .

Please check out the facts with your SHOP Exchange before jumping to conclusions.

Finally your employees won’t be “losers”–including the 23 year old, who probably won’t get sick, but is at risk for being in a bad car accident. (Much more commonplace among 20-somethings.) Moreover, under Obamacare he now lives in a country where his
mother and grandmother don’t have to worry about getting healthcare.

If he gets married in a few years, his wife will have good maternity benefits.

And right now, he will have free preventive care–something that everyone needs.

Finally, I don’t think that working 10-12 hour shifts is “good” for anyone–either the employee, or the clients/customers/ patients he is serving.

I am self employed, do not qualify for any of the subsidies and have happily purchased “crappy” major medical insurance for over twenty years. I like my low premiums, 100% coverage over the $10k deductible and my ability to take advantage of the negotiated rates the carrier has with the doctors, generally less than half the “street” price, or negotiate directly with the provider. My premium was $600 per month, and I dumped $400 per month into my HSA, which has accumulated over the years such that it now far exceeds my deductible, like by about five times. I will be losing this “crappy” plan and the most affordable replacement on the exchange would cost me $1,513 for the same deductible, has coverage for things I will never need and severely restricts my provider network. An extra grand per month for less product is not only not affordable, but not a prudent investment, either. I will instead allow my insurance to expire and instead dump the grand a month I have been currently paying into my IRA, which is protected from bankruptcy, and since I never am so foolish as to maneuver into a position where the IRS owes me money, I will not be paying any fines, either.
Two of my doctors are changing their practices to cash only, which is fine by me, and the others have sold their practices to hospitals, making both their availability and ability to provide custom service much more limited while at the same time increasing their rates and overhead. So, the bifurcated health delivery system will finally bloom and we will have the two-tiered system everybody has always dreaded, people of means or good financial judgement will participate in a market solution with doctors trying to provide the best service to the most number of customers at the lowest price, and the others will take whatever punishment or reward the government masterminds deem appropriate given their station in life, apparently as Maggie claims, due merely to good or bad “luck” and not due to hard work and wise lifestyle choices.

Let me respond just to your last sentence: “Hard work and wise lifestyle choices” will not protect you against the many risks that
we all face: Cancer, Alzheimer’s Parkinsons’s (or a great many other degenerative diseases), or a horrible accident

I have spent the last hour reading this entire stretch of blogs and I want to commend you on your ability to remain kind and informative even when others are being sarcastic and rude. One would think that school teachers would at least know how to have an intellectual conversation without being rude.
I have learned a great deal from reading this blog and appreciate your help to better understand what is really going on. I did not vote for O-care, it is not the governments right to control our health care. They are trying to take control of everything in our lives already. Big Government and Big Papa Pharmacia need to go down for the deception they have pulled over the eyes of many Americans. Doctors get kick backs for prescribing drugs, that’s why people are dying from taking too many pills.
If I may offer my own insight into this situation, it seams to me that many business owners are raising their coverage percentages because of the unknown. One cannot write a budget without knowing the income. You more or less said the same thing earlier.
People fear what is unknown and this is why companies are charging more from their employees healthcare. I believe that everything will even out in the wash when the system has been up and running for a while. The proof of lowered costs will then set business owners minds at ease and they will again be able to pay more of a percentage to offer coverage for their employees.
I understand fully how going from being a government employee with great insurance to an unemployed college student with no insurance, feels. My teeth are in really bad condition because I have had no dental for the last five years. It is very scary to be going without mammograms each year at the age of 46, too.
The question I have about Obama care is in regards to the attached addendum that gives the government the right to seize your estate if you owe huge medical bills upon your death. This addendum was not even discussed in public, it was hidden and pushed thru on the heals of the O-care act. This to me is shady and wrong, regardless of good intentions otherwise.

The government cannot “seize your estate if you owe huge medical bills” unless the patient has gone on Medicaid
If a patient is very sick and cannot pay his or her medical bills, and Medicare is no longer paying (Medicare caps how much it will pay over a lifetime_ then the patient’s relatives have a choice: they can pay the bills (if they are able to do that)–or
let the patient go on Medicaid.

Once a patient is on Medicaid, his or her assets (investments, home etc.) will be used to pay the bills. After the patient runs out of assets, Medicaid continues to pay the bills.

You wrote: “the story assumes that for a worker earning $21,000, most policies will eat up 9.5% of his income, or roughly $2,000. The reporter overlooks the fact that employers typically pay at least 2/3 of the premium.” -that’s an overgeneralized estimate. There are still plenty of small businesses who will only pay HALF, and that’s $1000 sucked out of a meager $21,000 income (4.76%). Don’t these people matter? When you make as little as $21,000 annually that $1000 is no small change. PLUS (fact), when your employer offers job-based health insurance and agrees to pay for a small portion, the employee no longer can go to the Marketplace website and get subsidization and tax credits — and the Marketplace plan (e.g., bronze plan) could have ended up cheaper with subsidization and tax credits. It’s an unfair circumstance for workers offered job-based insurance plans that they don’t like. Your article here is highly pro-Obamacare and too biased to simply be called “fact.” You are leaving out the facts that suggest anything is wrong with Obamacare.

In 2013 the average worker who had employer-based insurance contributed
18% of the premium for single coverage and 29%
of the premium for family coverage.

Covered workers in small firms (3-199 workers)
are more likely to work for a firm that pays 100%
of the premium for single coverage than workers
in large fi rms (200 or more workers). Thirty-two
percent of covered workers in small firms have an
employer that pays the full premium for single
coverage, compared to 6% of covered workers in
large firms . For family coverage,
14% percent of covered workers in small firms
have an employer that pays the full premium,
compared to 2% of covered workers in large firms

JUST Four percent of covered workers in small firms
(3–199 workers) contribute more than 50% of
the premium for single coverage, compared to
less than one percent of covered workers in large
firms (200 or more workers)
For family coverage, 31% of covered workers
in small firms work in a firm where they must
contribute more than 50% of the premium,
compared to 6% of covered workers in large firms
You will find the above facts here: http://kaiserfamilyfoundation.files.wordpress.com/2013/08/8465-employer-health-benefits-20132.pdf

In other words, if you work for a small company you are likely to be asked to contribute more
only if you are asking your employer to cover your family–not if your are asking for single coverage.

These days, most women work, so increasingly, employers want the woman’s employer to cover her.
They will cover an employee’s kids, but not his spouse. A working woman is not considered a “dependent.”

Also you should be glad to hear that Under Obamacare, most small businesses will have to meet all of the requirements of the legislation: free preventive care including free birth control, a cap on how much you can be asked to pay out of pocket, no cap on how much insurers have to pay out in a given year or over a lifetime; all 10 essential benefits (including mental health care, maternity, and other things that many small businesses now do not cover)

Plus when your employer pays even $1,000 toward your insurance, you do not have to pay taxes on that benefit (the way you pay taxes on your salary.) But that $1,00 is in fact compensation that increases your household’s income.

People who don’t have employer-based insurance don’t enjoy that tax break. For years, that have felt that is “unfair.”

Finally, if you earn $21,000, there is a good chance that you could find another job that pays $21,000 and does not offer health insurance. Then you could shop in the
Exchange and receive a subsidy.

Would you be better off? I have no way of knowing.

You may have a job you love. But if you don’t, and you don’t like your employer’s insurance, it’s up to you to weigh the advantages of various jobs and decide where you want to work. (I realized that in these days of high unemployment, changing jobs may not be easy, but today, there are a fair number of jobs out there that pay $21,000 with no health benefits.

Finally, Obamacare is designed to make sure that people who are uninsured can get insurance–and to ensure that people who do have insurance have good insurance. This is why even small businesses must meet Obamacare’s requirements–covering the 10 essential benefits, free preventive care, etc.

What about this statistic? An educated person who could not find a job for 2 years and now can’t afford to insure her family. It’s just so easy, right? Until it’s your family in a difficult situation. Keep your job and don’t have a family so that you can take care of those who sit at home and have one.

I am a 58 year old woman from Pennsylvania. I work an average of 30 – 35 hours a week at a pay rate of $7.85/hour at a local McDonalds. While I do qualify for food stamps I am ineligible for Medicad. I opted out of medical coverage offered by my employer because it was too expensive and the coverage was minimal. I have certain health issues but nothing that would qualify me for medical assistance. My manager is looking into if and what I may qualify thru my job. The whole process is confusing and quite frustrating for me. My manager is now on vacation and has not informed me as to my status and if I qualify for insurance from my job. As it were I had life insurance and dental insurance with mad co-pays thru my job all of which I may lose if my employer is unable to provide me coverage. Pennsylvania is one of the states that did not extend their options to qualify people for medical assistance. Do you have any suggestions as to how and what and where I should apply and might qualify for medical coverage? Any information you can provide would be appreciated.

I have a question….please explain to me how if the premium offered (after the employers contribution) could equal the same for all families (in this example) regardless of income….so if the premium a month is 600 for a family that only has 45000 a year (which is 16%)….vs another employee earning 75000 (9.6%) ?

How can that be accurate…and to top if off if you are offered insurance through your job, then you are not eligible to shop in the marketplace…. I don’t know about you..but my family cannot afford 600 a month on just a premium…not to mention that for a year all three of my kids only went to the doctor maybe once or twice and my bill was 1000 for the entire year…I’d be paying more in premiums and deductibles and copays that I would on my own…..and yes I know if it where something serious it would cover it, but its still unrealistic. 600 a month is almost a second mortgage and we are barely pulling through with our current mortgage….don’t have any savings because there is nothing left to save….and obama is forcing ppl in these situations to get insurance, even if they can’t afford it.

and before you say “well go to the marketplace”…remember….you CAN’T if insurance is offered through your company. But I also CAN’T pay that insurance either!!!

Luckily for me I am a veteran and am exempt from getting the penalty for not getting insurance as long as I am registered with the VA. Luckily for my family, our income awards us the ability to get medicaid or famis for the kids. So we all end up covered with a 5 dollar co pay and no premium. But not everyone in the USA is as lucky as me and I am sickened at the fact that if it weren’t for Medicaid for the kids and VA benefits for us, we’d either have to pay penalty fees or choose between our mortgage and health insurance. Its absolutely disgusting. And I am finding out that these premiums are normal…even before obama care. I don’t care what anyone says about it, I sometimes wish I lived in Canada or France where health insurance may not be perfect but it won’t put you on in bankrupcy or the street either. And Where the universities tuitions are non existant…..well….. I have my passport…..I guess I could try .

Carine — If your share of your employer-based insurance exceeds roughly 10% of your joint income, you are eligible to buy insurance in the Exchange, where you may receive a subsidy.
Call your local exchange for more information.

If you lived in France or Candada, your taxes would be roughly 30% higher than they are here. That’s how they pay for health insurance– largely through their tax system.
In general, people in these countries pay 10% of their gross income in taxes that are target to support universal healthcare. Americans just aren’t used to spending that much of their budget on health care because we have had employer sponsored healthcare for so long.

My husband took a new job with a company who charges $199.00 weekly rate for Value PPO Group Insurance. A total of $9,552.00 a year and that’s with a wellness program and a deductible of $6,000.00 Am I missing something or is this illegal??? Its down right ridiculous to even assume anyone could afford this??? Or is this a way the employer gets away with offering insurance knowing the employees will have to opt out and find their own?

Under Obamacare, the latest figures show that the average premium for a mid-tier (silver policy) is roughly $4,000 for one person. That would work out to around $8,000 for a couple.
If your husband is paying $9,500 to insure both of you, that’s higher than average–but not illegal.

However, here is what you need to know: if $9,552 is more than 9.5% of your joint income, you are eligible to buy insurance in local Obamacare Exchange, and there, depending on your income, you may well be eligible for a subsidy. (87% of people now buying insurance in the Exchanges receive subsidies.) The $6,000 deductible is particularly high.

My husband’s employer provides a plan for him. Spouses and children are not covered but may purchase employer insurance at a cost of nearly 20% of our household’s annual income. We are NOT eligible for a subsidy because by offering insurance to my husband only, ACA considers it “affordable.” How is this affordable? We cannot afford to devote 20% of our income to health insurance premiums.

The ACA means “affordable” for the individual worker. If his coverage (not family coverage) costs less than 9.5% of income, it’s considered affordable.

These days, most wives work, and so the Affordable Care Act doesn’t think of a wife as a “dependent”. The law assumes that the wife should get insurance through her own employer; she should not expect her husband’s employer to cover her. (At one time most employer-based plans covered spouses, but now they don’t.)

But what if you don’t want to work? Some women want to stay at home with their children. Here lawmakers decided that it wouldn’t be fair to subsidize stay-at-home-Moms when other mothers work.

Should the govt. be in the business of subsidizing stay-at-home mothers? I personally think that the govt should be subsidizing good daycare, so that working mothers don’t have to
worry about their kids. When my children were growing up, I always worked. I didn’t have any choice. But I also liked my work, and so didn’t see this as a problem.

Going back to your situation: paying 20% of your income to cover you and your kids just isn’t feasible.

But if your income is low, your children might well qualify for SCHIP (sometimes spelled CHIP). This is government insurance for children–like Medicaid, but it’s much easier to qualify. Check with your local Medicaid office.

The other possibility is that you might find a job that offers health benefits for you & the kids. Or your husband might begin looking for a job that offers better benefits.

I realize the job market is tight and that’s easier said than done.

But you should realize that the Affordable Care Act was designed to provide insurance for low-income and median income people who don’t have insurance at work–those are the neediest people. It wasn’t designed to help upper-middle-class people, the vast majority of whom do have employer-based insurance. And as I explained, it wasn’t designed to subsidize mothers so that they can stay at home with kids. No doubt some people think it should. But I know we can’t afford to do that.

At some point down the road (maybe in a year or two) people who have the option of insurance at work may be allowed to go into the Exchanges and purchase their own insurance there.. But they won’t get subsidies if they
are earning significantly more than median income (half of all Americans earn less, half earn more. Median household income (joint) is now around $60,000-$63,000).

There is “good in theory” and “good in reality” and often the two don’t match up.

What about people who DON’T WANT INSURANCE because they won’t ever use it, like me? I’d rather trust google and intuition than a doctor who gets paid off by pharmaceutical companies to prescribe me a drug that will hurt me, not heal me.

Why should I be fined for not wanting to pay for a service I won’t use?

Does the Affordable Care Act say anything about premiums charged to cover children on large group health plans? If you want to cover 3 or more children, is there an additional cost over covering 2 children? Most large group plans seem to work this way. Covering 1 child costs extra, then adding a second child costs more, but 3 or more children is the same premium as 2 children. Does ACA state that? I am on a large group plan with Blue Cross. Thank you.